1991, 04-13 Permit App: 91003328 ReroofPARCEL NUMBER:
INFORMATION WORKSHEET
Ua.
STREET ADDRESS:
CITY/STATE/SIP:_
SUBDIVISION:
: BLOCK: IAT: ZONE: -DISTRICT:
LOT ARBA: F/A: WIDTH.R�'W:
DEP'�fi:
# OF BUILDINGS:- # OF DWELLINGS:__ •WATER°DISTRICT
OWNER: PHONE:-_7r�
MAILING ADDREf ;U:-=
CITY/STATE/ZIP: p C -a e�4�,C1�� l
CONTACT: �� PK�� -_ PHONE
SETBACKS: FRONT: LEFT: RIGHT: '.REAR:
PERMIT USE:
BUILDING INFORMATION
CONTRACTOR LICENSE NUMBER:
CONTRACTOR: PHONE: �' r ,' - /
MAILING ADDRESS:
ARCHITECT/ENGINEER: PHONE: - -
MAILING ADDRESS:
NEW: REMODEL: K ADDITION: CHANGE OF USE:
DWE7 ", UNITS: OCCUPANT LOAD: BUILDING HGT: STORIES:
BUILrING DIMENSIONS: R (WIDTH R DEPTH) SQ. FT.:
REQUIRED PARKING: # HANDICAP: SEWER (Y/N): HYDRANT:
L
I"
PAY TO /) (/ a ( f
tsi
"INVOIC,E RECAP AND DISBURSEMENT VOUCHER
1" "t ')I
STORE NO. `1( 'r7
STORE
No. 378299
DATE ~In -9/
CUSTOMER'S NAME
SALESCHECK
NUMBER
JOB I.D. NO. OR
WORK ORDER NO.
AMOUNT
DUE
CONTRACTOR
t/
ACCOUNT
NUMBER
DIV.
NO.
ALLOCATION OF EXPENSE — FOR INSTALLATION OFFICE USE
ADJUSTMENT
I certify that the installations listed above have all been
completed satisfactorily in accordance with the speci
fications furnished me.
(CONTRACTOR'S SIGNATURE)
TOTAL
AMOUNT
OK TO PAY
TOT S
%! r
t
(AUTHORIZE D SIG
CHECK NO.
14489 (See Bul. 0-187 Part 11 Sum. 81 REV. 3/91 SEARS FORMS MANAGEMENT
(DATE)
ACCT.
ACCT.
PAYING UNIT NO.
CONTRACTOR
EXPENSE
MEMO
SELLING
4
PAYING
UNIT NAME
(If Different)